In times of financial crisis, it pays -- or, more fittingly, saves -- to explore unconventional ways to pull off major technology projects. For Midland Memorial Hospital, this came in the form of 1970s-era code unearthed via the Freedom of Information Act.

Major executive shakeup and financial losses in the millions left Midland Director of IS David Whiles at a loss as to how he and his team could breathe new life into the Texas-based hospital's aging IT infrastructure. The comprehensive EHR (electronic health-care records) system Midland needed to modernize its operations typically cost around $22 million. Thanks to 30-year-old code, creative partnerships, and a deep commitment to end-user training, Whiles and company found a way to do it for only $7 million.

The journey began six years ago as most IT projects do: with a year-and-a-half search for the right vendor. A dozen vendors showed up on Midland's radar, says Whiles, but "we didn't see anything we felt we could afford."

Whiles knew there had to be a cheaper route to EHR, which the hospital needed to convert paper-based processes into electronic ones for increased efficiency, security, and compliance with new regulations.

That's when Whiles looked outside of the traditional EHR vendor box and found VistA, EHR technology developed in the mid-1970s and used mostly by the U.S. Department of Veteran Affairs (VA). Based on open source code, VistA was made available to Midland free via the Freedom of Information Act. The price tag for hardware, software, and services to support VistA was irresistible: about a third of the cost of other EHR systems.

But many challenges awaited Midland's adoption of VistA. For starters, the code needed to be tweaked to match Midland's best practices -- yet Midland didn't have any programmers on staff. Also, interfaces had to be built for third-party systems so that VistA could handle operations outside the typical VA facility, such as ob-gyn (babies aren't often born at VA hospitals), acute care, and surgery, as well as sophisticated registration and billing that works with various insurance agencies.

To do this, Midland needed an integrator to help port VistA to a private hospital. Hardly anyone offered such a service, says Whiles, because "this was never done before." Whiles eventually found Medsphere, an unproven startup with no customers. But the possibility of a partnership with Medsphere exposed Midland to significant risks. What if Medsphere proved incapable of handling the multimillion-dollar, multiyear project? What if Medsphere suddenly went out of business?

To assess these risks, Midland turned to Deloitte Consulting, which provided a plan to mitigate them: gauge Medsphere consultants' willingness to sign on as Midland employees should Medsphere go belly up.

Whiles reached out to Medsphere under those conditions in December 2004, and the rollout began. Midland clinical analysts and Medsphere technical pros collaborated deeply for the better part of two years to develop the necessary interfaces for Midland's VistA-based EHR.

But the journey hit a road bump when it came to user adoption. Midland's new administration had promised employees -- which include some 800 clinical staff, 200 physicians, and 300 auxiliary workers -- that they wouldn't have to wait in line for a computer. "We put in an enormous amount of workstations around the hospital to accommodate that [promise], a lot more than we originally planned," Whiles says.

Even worse, many Midland staffers had never used a computer in their lives. One person chose to retire rather than learn about computers and EHR. Thus, Whiles created an aggressive campaign to teach people how to use the EHR system.

Whiles offered $1,000 to doctors who demonstrated that they were using the system through electronic signage and order entry, and he identified stragglers using the same metrics. "We targeted them every week," he says. Whiles also put out a monthly newsletter promoting EHR benefits and even created a naming contest -- the system is now called Edith.

The perseverance paid off, as now "everyone knows Edith," Whiles says. Midland rounded up charts in February and now runs completely on EHR. "The administration would never have allowed that if they didn't think the system was successful," he says.

This spring, the Health Information Management and Systems Society recognized Midland for having one of the highest levels of automation. The $7 million price tag for an assembled system, as opposed to $22 million for a top-of-the-line system, makes it sweeter. Sure, "Cadillac" EHR systems probably have more features and less need for tweaking code and building interfaces, says Whiles, "but I'll put ours up against anyone's."